Persistent Pain Eight Months After Anal Fissure Surgery: Patient Concerns

Persistent pain eight months after anal fissure surgery?

Hello Dr.
Chang, I had surgery last May for chronic anal fissure accompanied by mild stenosis.
The doctor performed debridement, and during the procedure, a small portion of my sphincter was cut, and my anus was enlarged using a vertical and horizontal suture technique.
Since the surgery, I have experienced pain that has gradually improved, but I still have discomfort.
I usually feel pain after using the restroom; my stool tends to be dry and hard at the beginning, and I have relatively bulky stools.
I go to the bathroom every morning, and if the initial part of the stool is larger and somewhat dry, I experience pain for several hours.
I would like to ask Dr.
Chang the following questions:
1.
After I have a bowel movement, I feel pain.
When I apply ointment with my finger, I can feel the surgical site, which still has a hard area.
Is this part the surgical scar? The area was initially large but has become smaller; however, it is still somewhat hard.
Is there a chance this will improve after eight months? If it doesn't improve, what should I do?
2.
I experience pain when using the restroom, but there is no bleeding.
The hard area I can feel with my finger, could it be a new anal fissure? Or is it just the surgical scar? If it is a new fissure, what would it feel like? (I am concerned that the old fissure hasn't healed and a new wound has formed.)
3.
I go to the bathroom every day, but the initial part of my stool is always dry and hard.
Is this normal? What methods can I use to improve this? I consume a lot of fiber and drink 3000cc of water daily, but I find it challenging to control the causes.
Drinking tea also seems to contribute.
I have been in pain for eight months since my surgery, and I really don't know what to do, so I came here to consult you.
Thank you for taking the time to read and answer my questions.

Jiu Xiansheng, 40~49 year old female. Ask Date: 2024/01/24

Dr. Zhang Shuhao reply Surgery

1.
If a longitudinal incision is required for the sphincter, it indicates that the previous narrowing was more severe, necessitating a broader area of relaxation.
The hard area felt by the finger is likely scar tissue from the surgery, which may improve over time.
Continuous sitz baths and the use of ointments can be beneficial.

2.
Scar tissue after surgery tends to have reduced elasticity, and new anal fissures are more commonly found in the anterior-posterior direction.
They may feel slightly depressed (though often not palpable), and there can be a tearing sensation during bowel movements, with pain potentially lasting for some time afterward.
3.
In most cases, 3000cc of water is sufficient, but it is important to note that tea or coffee can have diuretic effects, leading to fluid being excreted through urine rather than entering the intestines.
It is advisable to reduce caffeine intake and to use probiotics and stool softeners in moderation.
Post-surgical pain may improve, but if symptoms persist, a follow-up appointment is recommended to assess the wound and adjust medications.

Reply Date: 2024/01/24

More Info

It sounds like you are experiencing significant discomfort following your anal fissure surgery, and I understand how distressing this can be. Let’s address your concerns one by one.

1. Post-Surgery Pain and Scar Tissue: The pain you are experiencing after bowel movements, especially if it is associated with hard stools, could indeed be related to scar tissue from the surgery. Scar tissue can sometimes feel firm or hard to the touch, and it may take time to soften and become more pliable. Given that it has been eight months since your surgery, it is possible that the scar tissue may continue to improve, but this can vary from person to person. If the area remains hard and painful, it may be beneficial to consult your surgeon or a gastroenterologist for further evaluation. They may suggest treatments such as topical medications, physical therapy, or other interventions to help manage the scar tissue and associated pain.

2. Identifying New Fissures vs. Scar Tissue: The hard area you are feeling could be scar tissue, but it is also possible for new fissures to develop, especially if you are experiencing pain during bowel movements. New fissures typically feel sharp and may be accompanied by a burning sensation. If you are concerned that you might have developed a new fissure, it is essential to have this evaluated by your healthcare provider. They can perform a physical examination to determine the nature of the pain and whether it is due to scar tissue or a new fissure.

3. Bowel Movements and Stool Consistency: It is concerning that you are experiencing hard stools despite your efforts to increase fiber intake and hydration. Hard stools can exacerbate pain and lead to further complications, such as new fissures. It may be helpful to consider the following strategies to improve stool consistency:
- Dietary Adjustments: Continue to consume high-fiber foods such as fruits, vegetables, whole grains, and legumes. You might also consider adding a fiber supplement, such as psyllium husk, to your diet.

- Hydration: Ensure you are drinking enough fluids throughout the day. While you mentioned drinking 3000cc of water, it’s essential to maintain this level consistently.

- Stool Softeners: Over-the-counter stool softeners can help make bowel movements easier and less painful. These can be particularly useful if you are still experiencing hard stools.

- Regular Bowel Habits: Try to establish a routine for bowel movements, allowing yourself enough time and privacy to avoid straining.

If you continue to experience pain and difficulty with bowel movements, it may be beneficial to consult with a gastroenterologist or a colorectal surgeon. They can provide a comprehensive evaluation and may recommend additional treatments, such as medications to relax the anal sphincter or even further surgical options if necessary.

In summary, while some discomfort can be expected after anal fissure surgery, persistent pain and difficulty with bowel movements warrant further investigation. It is crucial to maintain open communication with your healthcare provider to address these issues effectively and improve your quality of life. Thank you for sharing your concerns, and I hope this information helps guide you toward a resolution.

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